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2 What Is Root Cause Analysis
ОглавлениеIt is not uncommon to see industries caught in the vicious cycle of failure, repair, blame, failure, repair, blame, etc. When there is premature failure of equipment, people involved often asked the question, whose fault it is. Many a time you will get the answer “it is other guy’s fault.”
If one were to ask a operator why the equipment fail, the immediate answer will be it was the fault of maintenance mechanic who had not fixed it properly. In the same line, a maintenance mechanic likely answer to that question would be “operator error.” At times, there is some validity to both these answers, but the honest and complete answer is much more complex. This chapter briefly introduces the concepts of failure analysis, root cause analysis, and the role of failure analysis as a general engineering tool for enhancing failure prevention.
Failure analysis is a process that is performed in order to determine the causes that may have attributed to the loss of functionality. These defects may come from a deficient design, poor material, mistakes in manufacturing or wrong operation and maintenance. Many a time there is no single cause and no single train of events that lead to a failure. Rather, there are factors that combine at a particular time to allow a failure to occur. Failure analysis involves a logical sequence of steps that lead the investigator through identifying the root causes of faults or problems.
Look at any well‐studied major disaster and ask if there was only one cause. Was there only one cause for the TITANIC? Three Mile Island? The Exxon Valdez mess? Bhopal? Chernobyl? It would be nice if there were only one cause per failure, because correcting the problem would then be easy. However, in reality, there are multiple causes to every equipment failure. Let us take the case of TITANIC failure.